-
Bile Duct Injury After Single IncisionLaparoscopic
Cholecystectomy
Kwan N. Lau, MD, David Sindram, MD, PhD, Neal Agee, MD,John B.
Martinie, MD, David A. Iannitti, MD
ABSTRACT
Background: The advancement and development oflaparoscopic
cholecystectomy revolutionized surgery andcase management. Many
procedures are routinely per-formed laparoscopically. Single
incision laparoscopic sur-gery has been introduced with the hope of
further reduc-tion of scarring and possibly procedural pain. With
noestablished technique for this procedure, the safety ofsingle
incision laparoscopic cholecystectomy has notbeen determined.
Methods and Results: A 30-year-old man underwentsingle incision
laparoscopic cholecystectomy for symp-tomatic cholelithiasis at an
outside hospital. The operationwas uneventful, and the patient was
discharged home.The patient returned to the Emergency Department 4
dayspostoperatively, and a bile duct injury was diagnosed.
Apercutaneous drain was placed, and the patient was trans-ferred to
the Hepato-Pancreato-Biliary (HPB) service of atertiary care center
for definitive care. A delayed repairapproach was used to allow the
inflammation around theporta to decrease. Six weeks after injury,
the patient un-derwent Roux-en-Y hepaticojejunostomy. The patient
didwell postoperatively.
Conclusion: Although single incision laparoscopic sur-gery will
play a prominent role in the future, its develop-ment and
application are not without risks as demon-strated from this case.
It is imperative that surgeons betterdefine the surgical approach
to achieve the critical viewand select appropriate patients for
single incision laparo-scopic cholecystectomy.
Key Words: Single incision laparoscopic cholecystec-tomy, Bile
duct injury.
INTRODUCTION
The advancement and development of laparoscopic cho-lecystectomy
revolutionized surgery and case manage-ment. Many procedures, such
as adrenalectomy, colec-tomy, hernia repair, and cholecystectomy
are routinelyperformed laparoscopically. Open cholecystectomy
hasbeen largely replaced by laparoscopic cholecystectomysince the
first reported case in 1987.1 As technologiesevolve, surgeons
continue to improve perioperative pa-tient outcomes by introducing
various methods to reduceport size and number. This pursuit of
scarless surgeryhas given rise to the concept of Natural Orifice
Translu-minal Surgery (NOTES) and single incision
laparoscopicsurgery. These approaches might offer significant
advan-tages for minimizing procedural pain and eliminating
orminimizing postoperative scars, while maintaining thesame safety
profiles and cost effectiveness. While thecurrent standard approach
for cholecystectomy is laparo-scopic cholecystectomy by a
multi-port minimally inva-sive technique, scattered series in the
literature have alsodescribed the early experiences of patients
undergoingsingle incision for cholecystectomy.28 Although it is
pre-mature to determine the complication rate from singleincision
laparoscopic cholecystectomy due to the smallnumber of reported
cases, one report suggests that thecomplication rate may be as high
as 16.6%.9 However, incontrast to laparoscopic cholecystectomy, no
significantinjury involving the porta hepatis has been reported
fol-lowing a single incision laparoscopic cholecystectomy.We report
the first bile duct injury from single incisionlaparoscopic
cholecystectomy.
CASE REPORT
The patient is a 30-year-old man who underwent singleincision
laparoscopic cholecystectomy at an outside hospital.The patients
operation was reportedly uncomplicated, andthe patient was
discharged the same day. The patient devel-oped abdominal pain and
fever on postoperative day 4 andsought medical attention.
Technetium-99m dimethyl acetan-ilide iminodiacetic acid
hepatobiliary (HIDA) scan demon-strated a biliary leak. The
patients management included acomputed tomography (CT),
percutaneous drainage of bi-loma (Figure 1), and an endoscopic
retrograde cholangio-
HPB Surgery, Division of Gastrointestinal and Minimally Invasive
Surgery, Depart-ment of General Surgery, Carolinas Medical Center,
Charlotte, North Carolina, USA(all authors).
Address correspondence to: David A. Iannitti, MD, Program
Director, Hepato-Pancreato-Biliary Surgery, Division of
Gastrointestinal and Minimally Invasive Sur-gery, Department of
Surgery, Carolinas Medical Center, 1000 Blythe Blvd. MEB
601,Charlotte, NC, 28203, USA. Telephone: (704) 355-6220, Fax:
(704) 355-4822, E-mail:[email protected]
DOI: 10.4293/108680810X12924466008646
2010 by JSLS, Journal of the Society of Laparoendoscopic
Surgeons. Published bythe Society of Laparoendoscopic Surgeons,
Inc.
JSLS (2010)14:587591 587
CASE REPORT
-
pancreatography (ERCP). The CT revealed diminution ofenhancement
throughout the right lobe of the liver, and thisfinding was
consistent with a right hepatic artery ligation. AnERCP
demonstrated complete occlusion of the common bileduct with no
communication to the proximal intrahepaticductal system (Figure 2).
The percutaneous drain continuedto drain bile, and the patient was
transferred to the HPBservice of a tertiary care center for
definitive treatment of acommon bile duct injury.
A delayed repair approach was chosen to allow the in-flammatory
tissue involving the porta to decrease anddelayed biliary injury to
manifest due to vascular compro-mise. Six weeks after the injury,
the patient was explored.Intraoperatively, the injury was
identified at the hilus ofthe liver. The common bile duct was
divided at the con-fluence of the left and right hepatic ducts, and
the distalduct was clip ligated. The left hepatic duct was
openedtransversely through the confluence (Figures 3 and 4).The
right anterior sector and the right posterior sectorducts were then
identified with coronary probes. The rightposterior sector duct was
identified as the dominantbranch. A handsewn end-to-side
hepaticojejunostomywas performed in an interrupted fashion with 5-0
PDSsuture. The patient had an uneventful postoperativecourse and
was discharged home on postoperative day 5.
DISCUSSION
It is well established that conventional laparoscopic
cho-lecystectomy following the guideline of critical view re-sults
in major bile duct or vessels injury in1% of patients(range, 0.3 to
0.95) with other complications 3%.1013
The relative safety associated with laparoscopic
cholecys-tectomy has led to its acceptance as the gold standard
forcholecystectomy. Significant factors contributing to the
Figure 1. Computed tomography showing a subhepatic
biloma(arrow).
Figure 2. Ligation of distal common bile duct with no filling
ofthe proximal common bile duct. Clip at the common bile
duct(arrow).
Figure 3. Intraoperative picture of the porta hepatis
showingtransection of the bile ducts at their confluence
(arrow).
Bile Duct Injury After Single Incision Laparoscopic
Cholecystectomy, Lau KN et al.
JSLS (2010)14:587591588
-
safety may be standardized technique involving carefuldissection
of the triangle of Calot with development of thecritical view of
safety, experience with laparoscopic cho-lecystectomy and other
laparoscopic procedures, im-provement in the laparoscopic
instruments,14 and routineuse of cholangiography.
Since the introduction of laparoscopic cholecystectomy,the
evolution of minimally invasive techniques has con-tinued the
search for a less invasive and painful procedurewith an emphasis on
decreasing the number, size, or bothnumber and size, of the
trocars. This has subsequently ledto the development of a single,
commercially available,multi-instrument plastic cylinder. The
single incision lapa-roscopic port is usually inserted through a
small umbilicalincision and provides excellent postoperative
cosmesis.15
However, cosmesis alone may not be sufficient to justifythe
potential operative risks from single incision laparo-scopic
cholecystectomy. Others have suggested that pa-tients may have less
postoperative pain from singleincision laparoscopic surgery. No
data currently existcomparing postoperative pain from single
incision lapa-roscopic cholecystectomy with that of conventional
lapa-roscopic cholecystectomy. Port reduction strategies
havepreviously led to the development of a
minilaparoscopicapproach, where minilaparoscopy is defined as
2-portlaparoscopic surgery with a standard size umbilical portand a
2-mm, lateral mini-port. A metaanalysis comparing
minilaparoscopic cholecystectomy with conventional lapa-roscopic
cholecystectomy failed to demonstrate significantimprovements in
surgical outcomes, including pain.16 Suchdata for single incision
laparoscopic cholecystectomy arecurrently lacking.
Recently, Chamberlain et al17 performed a comprehensivereview of
case series using single incision laparoscopiccholecystectomy. Of
the reported cases, 142 cholecystec-tomies were attempted by single
incision laparoscopictechnique; 130 of these cholecystectomies were
comple-ted.8,9,1825 Ten operations were converted to open casesdue
to difficult dissection or cystic artery hemorrhage. Themajority of
the patients were highly selected young peoplewith cholelithiasis.
Minor complications including subcuta-neous hematoma and bile leak
were reported with the com-plication rate ranging from 0% to16%.9
No major bile ductinjury was reported in this study.
The experience transitioning from open cholecystectomyto
laparoscopic cholecystectomy has taught us that a min-imum of 12
cases is necessary to decrease the complica-tion rate for
laparoscopic cholecystectomy.26 Similarly, theinitial learning
curve may result in an increased compli-cation rate for single
incision laparoscopic cholecystec-tomy. The minimum number for
single incision laparo-scopic procedures has yet to be determined.
Since mostsurgeons performing single incision laparoscopic
chole-cystectomy are trained in laparoscopic cholecystectomy,their
experience may translate to safer dissection of theCalots triangle
and hence a reduced learning curve.
A root cause analysis of the causes of bile duct injury
fromlaparoscopic cholecystectomy and identified 3 main fac-tors
contributing to injury.11,27,28 Interestingly, the majorityof the
injuries were attributed to the surgeons mispercep-tion of the
anatomy of the cystic duct and gallbladder. Itappears that most
injuries are not secondary to inadequateskills or fund of
knowledge. A similar approach should beapplied to single incision
laparoscopic cholecystectomy toensure surgeons can transfer the
mental anatomic modelfrom laparoscopic cholecystectomy to single
incisionlaparoscopic cholecystectomy and be vigilant before
di-viding the cystic duct and artery.
Intraoperative cholangiography is another tool that mayassist in
identifying the biliary anatomy during difficultdissection, and it
may be helpful to decrease the incidenceof bile duct injury in
laparoscopic cholecystectomy.29 Sur-geons who perform single
incision laparoscopic cholecys-tectomy should be experienced in
performing and inter-preting cholangiograms, because
misinterpretation of theimages is common.30 A single incision
laparoscopic cho-
Figure 4. Schematic of the bile duct injury, CBDcommon bileduct,
PHAproper hepatic artery, LHAleft hepatic artery,LHDleft hepatic
duct, Raright anterior duct, Rpright poste-rior duct, RHAright
hepatic artery.
JSLS (2010)14:587591 589
-
lecystectomy may need to be converted to a
laparoscopiccholecystectomy, if not open, when the operation is
com-plicated by uncertain anatomy or when bile duct injury
issuspected.
Regardless of the approach used to remove the gallblad-der, the
most reliable technique to prevent bile duct injuryis to obtain the
critical view of safety. This entails dissect-ing Calots triangle
free of all tissue except the cystic ductand artery, with the base
of the liver bed exposed. Al-though single incision laparoscopic
cholecystectomy islimited by restricted movements, difficulty to
achieve tri-angulation, poor visibility as a result of lack of
smokeevacuation, and inability to change the camera angle, thisvery
same standard should apply. If there is lack of pro-gression during
the procedure due to anatomical variantsor inadequate retraction
via a single incision, the surgeonshould convert to a 4-port or
open cholecystectomy. If thepatient has acute or chronic
inflammation, a large stone inthe pouch of Hartmann, adhesive bands
between thegallbladder and common hepatic duct or intrahepatic
gall-bladder, Calots triangle could be obliterated. This mayrender
dissection dangerous. A safe and acceptable strat-egy would be to
abort the procedure, place a drain andtransfer the patient to a
center with extensive hepatobili-ary expertise.27 We advocate not
using the infundibulartechnique, which involves clearing only the
tissue aroundthe cystic duct/CBD junction, which has a higher
likeli-hood of misidentification injury especially during
singleincision laparoscopic cholecystectomy.
Single incision cholecystectomy represents a surgical
in-novation that is developing so fast that its clinical
valida-tion is lacking. Traditionally, many surgical procedureswere
developed on a trial and error basis. This may raiseconcern for
patient safety. A framework to evaluate thesafety of new procedures
is necessary to protect patients;however, the framework must also
be flexible so as not toobstruct improvement in surgical
technique.31 Surgeonsinvolved in improving surgical procedures must
have athorough understanding of how various approaches workto
minimize patients risks. Ideally, the safety data for anew
technique should not be based on case series alonebut should be
evaluated in a randomized controlled fash-ion. An online database
should be created for single inci-sion cholecystectomy, perhaps
similar to the one createdby the Natural Orifice Surgery Consortium
for Assessmentand Research (NOSCAR) group, with all cases recorded
ina registry.32 It will allow critical evaluation of outcomes
ofpatients undergoing single incision cholecystectomy andmay
facilitate standardization of outcome comparisons.
While single incision laparoscopic cholecystectomy mayplay an
important role in the future of minimally invasivesurgery, its
development and application is not withoutrisks as demonstrated by
this case report. It is imperativethat surgeons better define the
surgical approach toachieve the critical view of safety and select
the appropri-ate patients. Combined with further advances in
singleincision laparoscopic instrumentation, such as
articulatinginstruments and flexible laparoscopes, the clinical
out-come for single incision laparoscopic cholecystectomycan be
expected to improve. The safety profile for singleincision
laparoscopic cholecystectomy requires furtherprospective study to
compare standard laparoscopic cho-lecystectomy with single incision
laparoscopic cholecys-tectomy.
References:
1. Kaiser AM, Corman ML. History of laparoscopy. Surg OncolClin
N Am. 2001;10(3):483492.
2. Ponsky TA, Diluciano J, Chwals W, Parry R, Boulanger S.Early
experience with single-port laparoscopic surgery in chil-dren. J
Laparoendosc Adv Surg Tech A. 2009;19(4):551553.
3. Ersin S, Firat O, Sozbilen M. Single-incision
laparoscopiccholecystectomy: is it more than a challenge? Surg
Endosc. 2010;24(1):6871.
4. Lukovich P, Kupcsulik P. NOTES and other minimally inva-sive
surgical techniques of similar disciplines (hybrid NOTES,NOTUS,
SPS, SILS), and their impact on surgical approaches [inHungarian].
Magy Seb. 2009;62(3):113119.
5. Cugura JF, Jankovic J, Kulis T, Kirac I, Beslin MB.
Singleincision laparoscopic surgery (SILS) cholecystectomy: where
arewe? Acta Clin Croat. 2008;47(4):245248.
6. Barbaros U, Dinccag A. Single incision laparoscopic
sple-nectomy: the first two cases. J Gastrointest Surg.
2009;13(8):15201523.
7. Cugat Andorra E, Garcia-Domingo MI, Fonollosa EH, RiveroDeniz
J, Molina CM. [Cholecystectomy using single-incision lapa-roscopic
surgery (SILS)]. Cir Esp. 2009;85(5):315317.
8. Merchant AM, Cook MW, White BC, Davis SS, Sweeney JF,Lin E.
Transumbilical Gelport access technique for performingsingle
incision laparoscopic surgery (SILS). J Gastrointest
Surg.2009;13(1):159162.
9. Tacchino R, Greco F, Matera D. Single-incision
laparoscopiccholecystectomy: surgery without a visible scar. Surg
Endosc.2009;23(4):896899.
10. McMahon AJ, Fullarton G, Baxter JN, ODwyer PJ. Bile
ductinjury and bile leakage in laparoscopic cholecystectomy. Br
JSurg. 1995;82(3):307313.
Bile Duct Injury After Single Incision Laparoscopic
Cholecystectomy, Lau KN et al.
JSLS (2010)14:587591590
-
11. Strasberg SM, Hertl M, Soper NJ. An analysis of the
problemof biliary injury during laparoscopic cholecystectomy. J Am
CollSurg. 1995;180(1):101125.
12. Targarona EM, Marco C, Balague C, et al. How, when, andwhy
bile duct injury occurs. A comparison between open andlaparoscopic
cholecystectomy. Surg Endosc. 1998;12(4):322326.
13. Tuveri M, Pisu S, Demontis R, Medas F, Nicolosi A.
[Iatro-genic lesions of the common bile duct in laparoscopic
cholecys-tectomy: three fundamental requirements for their
prevention].Chir Ital. 2007;59(2):171183.
14. Sindram D, Portenier D. Complications of laparoscopic
cho-lecystectomy. In: Pappas TN, Pryor AD, Harnisch MC, eds.
Atlasof Laparoscopic Surgery. Philadelphia PA: Springer; 2008.
15. Langwieler TE, Nimmesgern T, Back M. Single-port access
inlaparoscopic cholecystectomy. Surg Endosc.
2009;23(5):11381141.
16. McCloy R, Randall D, Schug SA, et al. Is smaller
necessarilybetter? A systematic review comparing the effects of
minilaparo-scopic and conventional laparoscopic cholecystectomy on
pa-tient outcomes. Surg Endosc. 2008;22(12):25412553.
17. Chamberlain RS, Sakpal SV. A comprehensive review
ofsingle-incision laparoscopic surgery (SILS) and natural
orificetransluminal endoscopic surgery (NOTES) techniques for
chole-cystectomy. J Gastrointest Surg. 2009;13(9):17331740.
18. Cuesta MA, Berends F, Veenhof AA. The invisible
cholecys-tectomy: A transumbilical laparoscopic operation without
ascar. Surg Endosc. 2008;22(5):12111213.
19. Gumbs AA, Milone L, Sinha P, Bessler M. Totally
transum-bilical laparoscopic cholecystectomy. J Gastrointest Surg.
2009;13(3):533534.
20. Navarra G, Pozza E, Occhionorelli S, Carcoforo P, Donini
I.One-wound laparoscopic cholecystectomy. Br J Surg.
1997;84(5):695.
21. Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R,
Sent-hilnathan P, Praveenraj P. Transumbilical flexible
endoscopic
cholecystectomy in humans: first feasibility study using a
hybridtechnique. Endoscopy. 2008;40(5):428431.
22. Piskun G, Rajpal S. Transumbilical laparoscopic
cholecystec-tomy utilizes no incisions outside the umbilicus. J
LaparoendoscAdv Surg Tech A. 1999;9(4):361364.
23. Rao PP, Bhagwat SM, Rane A. The feasibility of single
portlaparoscopic cholecystectomy: a pilot study of 20 cases.
HPB(Oxford). 2008;10(5):336340.
24. Romanelli JR, Mark L, Omotosho PA. Single port laparo-scopic
cholecystectomy with the TriPort system: a case report.Surg Innov.
2008;15(3):223228.
25. Zhu JF, Hu H, Ma YZ, Xu MZ, Li F. Transumbilical endo-scopic
surgery: a preliminary clinical report. Surg Endosc.
2009;23(4):813817.
26. A prospective analysis of 1518 laparoscopic
cholecystecto-mies. The Southern Surgeons Club. N Engl J Med.
1991;324(16):10731078.
27. Strasberg SM. Error traps and vasculo-biliary injury in
lapa-roscopic and open cholecystectomy. J Hepatobiliary
PancreatSurg. 2008;15(3):284292.
28. Way LW, Stewart L, Gantert W, et al. Causes and preventionof
laparoscopic bile duct injuries: analysis of 252 cases from ahuman
factors and cognitive psychology perspective. Ann
Surg.2003;237(4):460469.
29. Flum DR, Dellinger EP, Cheadle A, Chan L, Koepsell
T.Intraoperative cholangiography and risk of common bile ductinjury
during cholecystectomy. JAMA. 2003;289(13):16391644.
30. Olsen D. Bile duct injuries during laparoscopic
cholecystec-tomy. Surg Endosc. 1997;11(2):133138.
31. Barkun JS, Aronson JK, Feldman LS, et al. Evaluation
andstages of surgical innovations. Lancet. 2009;26
374(9695):10891096.
32. Rattner D, Kalloo A. ASGE/SAGES Working Group on Nat-ural
Orifice Translumenal Endoscopic Surgery. October 2005.Surg Endosc.
2006;20(2):329333.
JSLS (2010)14:587591 591